Periconception HIV Risk Behavior Among Men and Women Reporting HIV-Serodiscordant Partners in KwaZulu-Natal, South Africa

Abstract

HIV-infected men and women who choose to conceive risk infecting their partners. To inform safer conception programs we surveyed HIV risk behavior prior to recent pregnancy amongst South African, HIV-infected women (209) and men (82) recruited from antenatal and antiretroviral clinics, respectively, and reporting an uninfected or unknown-HIV-serostatus pregnancy partner. All participants knew their HIV-positive serostatus prior to the referent pregnancy. Only 11% of women and 5% of men had planned the pregnancy; 40% of women and 27% of men reported serostatus disclosure to their partner before conception. Knowledge of safer conception strategies was low. Around two-thirds reported consistent condom use, 41% of women and 88% of men reported antiretroviral therapy, and a third of women reported male partner circumcision prior to the referent pregnancy. Seven women (3%) and two men (2%) reported limiting sex without condoms to peak fertility. None reported sperm washing or manual insemination. Safer conception behaviors including HIV-serostatus disclosure, condom use, and ART at the time of conception were not associated with desired pregnancy. In light of low pregnancy planning and HIV-serostatus disclosure, interventions to improve understandings of serodiscordance and motivate mutual HIV-serostatus disclosure and pregnancy planning are necessary first steps before couples or individuals can implement specific safer conception strategies.

A Systematic Review of the Current Status of Safer Conception Strategies for HIV Affected Heterosexual Couples in Sub-Saharan Africa

“…Factors affecting SCS availability from the individual or couple’s perspective included lack of awareness about safer conception services [20, 22, 33, 36–42] and limited integration of services for sexual and reproductive health into HIV care [43–45]. Few patients discussed fertility goals with providers, and discussions around pregnancy focused on maternal and child health and not on sexual HIV transmission [39–41, 46].…”

“…Mmeje et al found that HIV-infected individuals experienced stigma from their communities and fear of vertical transmission, so do not discuss fertility intentions with their providers [54]. Other studies found that education and building awareness around SCS impacts uptake and acceptability of safer conception services in HIV-affected couples [25, 36, 46, 55, 56, 59, 60], but patients fear of judgment for wanting children remained a barrier to receiving SCS counseling and education [27, 46, 51, 54]. …”

“…The review found that SCS were largely unavailable in sub-Saharan Africa outside of research settings, except for general availability (i.e., not for safer conception specifically) of ART and VMMC. Availability of SCS methods was greatest in public health facilities providing general services for people living with HIV [20–26, 31, 36, 39–44, 47–50, 56, 58, 59, 62, 63, 66–68]. More advanced or expensive strategies such as sperm washing, or PrEP remain unavailable in most public health facilities due to cost and lack of provider training [14–17, 23].…”

“…While HIV affected couples were generally eager to learn more about safer conception [27, 36, 39, 44, 46, 48, 51, 54, 72–74], there are numerous barriers to SCS access including stigma around HIV-affected couples wanting and bearing children [46]. Like our review, a recent consensus statement supporting safer conception and pregnancy for couples living with HIV found that access to SCS is limited by stigma toward HIV affected couples having children and that this stigma limits provision of safer conception services [75].…”

Prevalence and Correlates of Use of Safer Conception Methods in a Prospective Cohort of Ugandan HIV-Affected Couples with Fertility Intentions

“…About one-third of the sample reported using TUI at any time during the study, which is more than the studies conducted in South Africa that found rates of 3% [30] and 17% [22], although our time frame was longer. The validity of self-reported data regarding TUI use is challenged by social desirability, but also the difficulty in assessing whether participants who report using the method, used it correctly.…”